The Use of Live Streaming Technologies in Surgery: A Review of the Literature.

BACKGROUND: Live streaming surgery is a developing communication platform in medicine. To maximize the technological advances that allow for the live streaming of surgery, it is crucial to have an understanding of the various video-capturing devices that are available and their pros and cons of implementation. Possible barriers to the widespread use of live streaming surgery include cost, concerns about patient safety and privacy, and limited understanding of the current available resources. In this article, we present the results of our literature review of techniques for live streaming of surgery as a means to inform readers and promote their implementation. METHODS: We conducted a literature review of the literature to identify previous articles indexed in PubMed and Ovid. We used the following search terms: [Surgery AND Streaming], which generated 32 articles for initial review. References were reviewed within each document to find similar articles that were not captured by the initial search. The article selection criteria were peer-reviewed publications, case reports, and case series describing the use of live surgical streaming technologies. RESULTS: Literature review showed enhanced surgeon interaction with viewers and improved anatomy scores with the widespread use of live streaming. Surgeons reported positive feedback and wished to engage in more sessions in the future. The largest barriers to implementation of streaming technology are video quality through the Internet and patient information protection. CONCLUSIONS: Live streaming of surgery for educational purposes has not been widely accepted in surgical training programs to date. Streaming accessibility has advanced over the past 2 decades with the availability of handheld mobile devices. However, little has been done to allow for live streaming of surgery to trainees in a manner compliant with the Health Portability Insurance and Accountability Act.

Self-development Tools Utilized by Plastic Surgeons: A Survey of ASPS Members.

The plastic surgery literature is devoid of research on the topic of professional development tools that may be used to enhance performance as a plastic surgeon. After an extensive review of the medical literature, we selected the most frequently referenced professional development tools utilized by plastic surgeons, which included the following: goal setting, positive visualization, scheduled practice, critically analyzing mistakes, professional development conferences, involvement in sports, motivational videos, podcasts & audiobooks, daily morning routines, self-development books, and advice from mentors. METHODS: A 10-question survey was sent to 2542 members of the American Society of Plastic Surgeons (ASPS). The algorithm used to select ASPS members to survey was based on member demographics that would best reflect the views of the entire active society membership. Responses were compared based on demographic factors such as type of practice, gender, and age. RESULTS: A total of 286/2542 (11.25%) ASPS members participated in the survey. Analyzing mistakes (96.3%), goal setting (88.51%), and advice from mentors (85.2%) were most commonly attributed to self-development. Respondents in an academic practice favored conferences and advice from mentors. Participants in a solo practice favored self-help books and morning routines. No statistical differences were observed based on training background. CONCLUSIONS: ASPS members attribute their professional development to setting measurable goals, carefully analyzing surgical mistakes, and guidance from mentors. This information opens the door for continued analysis of professional development within plastic surgery as well as supplement training practices at the resident and post-graduate level.

Untethered and HIPAA-compliant Interactive Livestreaming of Surgery to Residents and Medical Students.

Traditional livestreaming of surgery to an audience requires stationary video broadcasting infrastructure, with viewers congregating in front of a screen, while audiovisual technicians provide support in the background. In recent years, livestreaming technologies from cameras to teleconference platforms have advanced dramatically, even to allow for compliance with the Health Insurance Portability and Accountability Act of 1996 with web-based encryption. The objective of this article is to show that livestreaming surgery in medical education is possible using portable devices, with the resident and medical students as audience at home interacting on their computer or smart devices. The surgeon utilizes a head-mounted camera transmitting video feed using a wireless transmitter broadcasting to a laptop computer, which is hosting a Health Insurance Portability and Accountability Act-compliant version of Zoom. The entire setup is portable, and the surgeon is tethered neither to a cord nor to the institution's audiovisual enterprise. This prototype setup allows the surgeon to broadcast live surgery interactively at any time and from any operating room with remote medical students and surgical residents. We posit that our medical education industry would need to condense the devices into a turnkey livestreaming camera system with optimized frames per second reception.

Infectious Complications Associated with the Use of Integra: A Systematic Review of the Literature.

Dermal regeneration templates such as Integra are effective reconstructive biomaterials used in a variety of soft-tissue defects. Fully understanding the complications associated with their use is paramount to improve outcomes and maximize patient safety. In this study, our purpose is to perform a comprehensive literature review to assess the previously reported infectious complications linked to Integra-based wound closure. METHODS: We conducted a systematic review of the literature to identify previous articles indexed in PubMed and Ovid for Integra and its synonymous terms. We used these search terms: [Integra OR (dermal regenerative matrix) OR (dermal regeneration matrix) OR (dermal regenerative template) OR (dermal regeneration template) OR (dermal substitute) OR (skin substitute) OR (artificial skin)] AND infection. RESULTS: Of the 3508 articles for initial review, 69 reported rates of infection, of which 26 reported ≥1 infection within their cohort. Of these 26 articles, the patients (n = 602) underwent Integra-based reconstruction in 1254 sites and had reported infections in 212 of the sites (16.9%). Among these, we encountered a single report of a fatal case of toxic shock syndrome (TSS) related to the use of Integra in secondary burn reconstruction. CONCLUSIONS: While Integra offers many benefits, surgeons must be aware that infectious complications are not uncommon. As a result, a careful risk-benefit analysis of its use in reconstruction must be performed, and open discussion with the patient preoperatively regarding infection rate is of utmost importance.

IntegraⓇ dermal regeneration template as the nidus of staphylococcal toxic shock syndrome: A case report.

The literature describes numerous successful applications using dermal regeneration templates such as IntegraⓇ. Despite widespread use for burns, trauma, and chronic wounds among others, Integra has associated complications which need continued investigation. Large multi-center studies designed to investigate its safety have shown that infections are the most common complications. In this case report, we share our experience with a patient who developed toxic shock syndrome (TSS) following abdominal scar revision with Integra. The literature reviewed identified one report of TSS in association with Integra use, which was fatal. In our case, the patient recovered uneventfully as a result of early recognition, expedient debridement, and appropriate antibiotic administration. Acknowledging that TSS is a rare but potential complication associated with the use of Integra is crucial for early recognition which will improve patient outcomes and reduces mortality.

Management of a Case of Mucor Colonization in Breast Tissue Expander Seroma Pocket.

Mucormycosis has a mortality rate reaching 90%, and is imperative that therapy be initiated rapidly once a diagnosis is made. Successful treatment consists of management of underlying risk factors, surgical debridement, and antifungal therapies. The dilemma whether or not to pursue extensive debridement presents when the wound is cultured positive but the patient is not systemically ill. We present the first reported case of successful medical treatment of a seroma pocket colonized with mucor in a patient undergoing bilateral reconstruction with tissue expander and acellular dermal matrix.

Enabling Remote Monitoring Using Free Apps and Smart Devices for a Free-Flap Adjunct Monitor.

Remote monitoring capability does not currently exist for Periflux (Perimed AB, Järfälla, Sweden) laser Doppler and other perfusion monitors. Two simple adaptations using free apps (applications) and smart devices can enable transmission of the perfusion readout to the surgeon's smartphone. A literature review was conducted to identify reports relating to remote free flap monitoring. In addition, 2 wireless methodologies are devised: One method uses a free app that converts a smart device into a camera, stationed next to the perfusion monitor, to stream live video of the laser Doppler readout to the surgeon's smartphone; a second method uses a free app installed on a bedside laptop computer, which is connected to the laser Doppler flowmeter via a data cord. A live feed of the computer's desktop as a teleconference host is transmitted to the surgeon's smart device over the Internet. These 2 methodologies were employed on 9 and 8 free flaps, respectively, as a pilot study. All free flaps were monitored remotely for 4-6 days with near 100% reliability. The Internet connectivity became disrupted only on several occasions, requiring simple Wi-Fi and software reset. Minor mechanical issues were encountered with the video streaming method. Literature review identified very few articles describing remote monitoring of free flaps. The 2 methodologies reported here provided reliable continuous transmission of quantitative data of flap perfusion to smart devices via Internet connection, which can revolutionize the microsurgeon's practice if his/her adjunctive perfusion monitor with display does not yet have Wi-Fi capability.

Obesity-related Risk Factors in Implant-based Breast Reconstruction Using AlloDerm.

With a population in which 70% of the patients were overweight or obese, we reviewed retrospectively 135 breasts of 70 consecutive patients who underwent implant-based immediate breast reconstruction using freeze-dried AlloDerm as the acellular dermal matrix. Several obesity-related parameters were evaluated to determine their possible correlation to early postoperative complications. We found that breast width and surface area of AlloDerm usage correlated with the development of infection and mastectomy skin flap necrosis. Increased breast width and size of AlloDerm matrix implanted were correlated with higher rates of both minor and significant skin necrosis and of cellulitis. Body mass index was correlated with the development of cellulitis and minor and major skin necrosis but not with seroma or reconstruction failure. Preexisting breast cup size correlated with the development of seroma but not the other complications. We observed no statistically significant association between reconstruction failure and any of the parameters reviewed, but this is likely due to the small number of failures in our data set (n = 10).

Limb salvage and reconstruction following a zebra attack.

Animal bites are fairly rare events but can cause devastating traumatic injuries to the victim. In addition to the soft tissue, vascular, and orthopedic trauma inflicted by these occurrences, bite injuries also have the potential to introduce an inoculum of microbes, which may progress to an infection if not treated properly and expeditiously. We present the case of a healthy male who sustained multiple bite wounds from a domestic zebra to his left upper extremity. This attack caused severe damage, including devascularization of the arm at the brachial artery, disruption of the distal biceps and brachialis, stripping of the forearm nerves, and shearing of the overlying soft tissue. The patient was taken emergently to the operating room for revascularization of the extremity utilizing a vein bypass graft. The soft tissue injuries were addressed with numerous irrigation and debridement procedures, during which coverage of the vein bypass graft was obtained using a variety of techniques, including skin flaps, musculocutaneous advancements, and the application of an acellular dermal matrix (AlloDerm) and a collagen-glycosaminoglycan matrix (Integra). Wound cultures obtained intra-operatively during the irrigation and debridement procedures were notable for the growth of multiple microbes, including Rhodococcus spp., which have been documented to cause infection in immunocompromised patients. The patient in this case was treated with a prolonged course of antibiotics, and wound cultures negative for microbial growth were eventually obtained prior to final closure of his wound. The patient then underwent successful biceps reconstruction with a pedicled latissimus dorsi muscle transfer. This case documents the extraordinary multidisciplinary approach provided in the salvage, management, and eventual reconstruction of a mangled left upper extremity that had sustained devastating traumatic injuries resulting from a rather unusual source.

Applying a Dermal Regenerative Template in Management of Congenital Melanocytic Nevi of the Hand.

Congenital melanocytic nevus of the hand in the pediatric population is an uncommon diagnosis. These lesions have malignant potential and can cause psychosocial effects from cosmetic deformity. Early surgical intervention is recommended in these cases. The literature suggests that full-thickness skin grafting is to be performed in the hand to maintain functionality and avoid contracture and scarring. This creates a large donor-site defect and increased risk of graft loss due to slow revascularization from graft thickness. In addition, for large defects, the full-thickness skin graft donor site would require a split-thickness graft. However, split-thickness skin grafting is avoided in the hand due to increased scarring and contracture and decreased range of motion despite decreased donor-site morbidity and better revascularization. We describe a novel reconstructive technique that uses a dermal regenerative template (Integra) with split-thickness grafting. Having performed in 2 pediatric patients, we demonstrate that aesthetic and functional outcomes are equivalent to full-thickness grafting while creating a superficial donor site and allowing for improved revascularization from decreased graft thickness.

Comparison between Freeze-dried and Ready-to-use AlloDerm in Alloplastic Breast Reconstruction.

BACKGROUND: AlloDerm, a brand of acellular dermal matrix, is commonly used as an internal hammock to support the tissue expander or permanent implant in breast reconstruction. The aim of our study is to evaluate the complication rates associated with the freeze-dried (FD) AlloDerm and the ready-to-use (RTU) AlloDerm. METHODS: This institutional review board-approved retrospective study involved 103 patients who underwent immediate postmastectomy breast reconstructions from June 2011 to August 2012. The first 51 patients underwent 96 immediate breast reconstructions with FD AlloDerm. The subsequent 52 patients underwent 100 immediate breast reconstructions with RTU AlloDerm. Patient demographics, postoperative complication rates in study cohort, and complication rates stratified by body mass index (BMI) were analyzed. RESULTS: Multiple patient demographics in the 2 cohorts are closely matched (P > 0.05). RTU AlloDerm was associated with higher rates of seroma and cellulitis compared with FD AlloDerm (22.0% vs 18.8%, P = 0.599 and 21.0% vs 12.5%, P = 0.129, respectively). Significantly higher rates of seroma and cellulitis were found in patients with BMI ≥ 30 compared with BMI < 30 (34.5% vs 9.2%, P < 0.001 and 29.9% vs 6.4%, P < 0.001, respectively). A generalized linear mixed model shows that obesity and RTU AlloDerm are statistically significant predictors of cellulitis (adjusted odds ratio = 10.413, P < 0.001 and adjusted odds ratio = 3.712, P = 0.011, respectively). CONCLUSIONS: Our study demonstrates a clinically higher postoperative complication rate in immediate breast reconstruction with RTU AlloDerm compared with FD AlloDerm and highlights the unfavorable risk factor correlation with significant obesity.

Free-flap failure in thrombophilia: case report and systematic review of the literature.

Free-tissue transfer has become routine surgery because of standardization of instrumentation, techniques, and training. The incidence of microvascular thrombosis leading to free-flap failure is relatively low; however, anastomotic thrombosis can still occur despite the best of circumstances. Although majority of the time it is due to technical mishap or misjudgment, free-flap failure can occur due to intrinsic factors, such as the patient's increased propensity to develop clots. We describe a case report of a patient with malignancy and multiple thrombophilias, which led to 2 successive failures in microvascular flap transfer to restore abdominal domain. The aim o f this article is to increase awareness of the potential for thrombophilias to cause a dismal outcome in free-tissue transfer. A review of the literature will be presented, and published cases of free-flap failure in patients with thrombophilia(s) will be summarized.

Hypothenar hammer syndrome: an update with algorithms for diagnosis and treatment.

Hypothenar hammer syndrome is an uncommon cause of symptomatic ischemia of the hand secondary to the formation of aneurysm or thrombosis of the ulnar artery as a result of repetitive trauma to the hypothenar region. The injury to the palmar ulnar artery occurs in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space. Such injuries of the ulnar artery may lead to severe vascular insufficiency in the hand with thrombosis and distal embolization of the digital arteries. Imaging of vascular lesions of the hand has greatly improved in recent years with the use of Doppler, multislice computed tomographic angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. The aim of this article is to describe a case report using current-day imaging and to present a review of literature. Algorithms for the diagnosis and treatment of hypothenar hammer syndrome will be proposed.

Combining use of resin models with external fixation in mandibular reconstruction.

OBJECTIVE: To obtain accurate occlusion in mandibular reconstruction when the tumor is exophytic, which makes prebending the plate impossible. DESIGN AND SETTING: Use of computed tomography-based resin models and external fixation devices is combined in a tertiary academic center. The exophytic part of the tumor on the model is burred off, and the reconstruction plate is bent on the model before surgery. Temporary external fixation is applied before resection, and a precontoured plate is applied following segmental resection before the release of external fixation. RESULTS: Six patients underwent mandibular reconstruction by using this technique, and all of the patients retained a class 1 occlusal relationship without need for additional intraoperative plate contouring. CONCLUSION: Computer-generated resin models of the mandible combined with intraoperative temporary external fixation allow the maintenance of preoperative occlusal status.